<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html lang="en" xmlns:wicket="http://wicket.apache.org">
<wicket:extend>
    <div class="row-fluid">
        <div class="span12">
            <h1 class="pageTitle">Specifieke gegevens</h1>
        </div>
    </div>
    <div class="row-fluid form-horizontal">
        <fieldset>

            <wicket:container wicket:id="paspoort"></wicket:container>

            <form wicket:id="form">
                <fieldset>
                    <div class="row-fluid">
                        <div class="span6">
                            <legend>Uniek identificerende codes</legend>
                            <div class="control-group">
                                <label class="control-label">Lijst van ZInstrumentName's gescheiden door komma's</label>

                                <div class="controls">
                                    <input wicket:id="instrumentNames" class="input-xxlarge" type="text">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Lijst van UserId Scanners gescheiden door komma's</label>

                                <div class="controls">
                                    <input wicket:id="userIdScanners" class="input-large" type="text">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">ORU-berichten verwerken</label>
                                <div class="controls">
                                    <input wicket:id="oruBerichtenVerwerken" type="checkbox">
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <legend>Financi&euml;le gegevens</legend>
                            <div class="control-group">
                                <label class="control-label">IBAN <i class="icon-asterisk icon-purple"></i></label>
                                <div class="controls">
                                    <input wicket:id="iban" class="input-large" type="text">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Tenaamstelling <i class="icon-asterisk icon-purple"></i></label>
                                <div class="controls">
                                    <input wicket:id="ibanTenaamstelling" class="input-large" type="text">
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Organisatie gerelateerde instellingen</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Medisch microbioloog</label>

                                <div class="controls">
                                    <textarea rows="3" style="width: 90%;" wicket:id="medischMircobioloog"/>
                                </div>
                            </div>

                            <div class="control-group">
                                <label class="control-label" type="text">Handtekening</label>
                                <div class="controls">
                                    <wicket:container wicket:id="handtekeningMedischMircobioloog"></wicket:container>
                                </div>
                            </div>

                            <div class="control-group">
                                <label class="control-label">E-mail voor signalering <i class="icon-asterisk icon-purple"></i></label>

                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="bmhkLabWarnMail">
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Patholoog</label>

                                <div class="controls">
                                    <textarea rows="3" style="width: 90%;" wicket:id="patholoog"/>
                                </div>
                            </div>

                            <div class="control-group">
                                <label class="control-label" type="text">Handtekening</label>
                                <div class="controls">
                                    <wicket:container wicket:id="handtekeningPatholoog"></wicket:container>
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>

                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Gekoppelde gemeentes</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span12">
                            <wicket:container wicket:id="gemeentes"></wicket:container>
                        </div>
                    </div>
                </fieldset>

                <div class="row-fluid">
                    <div class="span12">
                        <div class="form-actions btn-bottom">
                            <button wicket:id="annuleren" class="btn">Annuleren</button>
                            <button wicket:id="submit" class="btn btn-primary">Opslaan</button>
                        </div>
                    </div>
                </div>
            </form>
        </fieldset>
    </div>
</wicket:extend>
</html>
